MANUAL THERAPY LUMBER SPINE
SELECTION OF THE TECHNEQUES
Prepared by:
MUHAMMAD IBRAHIM KHAN
BS.PT(Pak), MS.PT(Pak), NCC(AKUH)
OBJECTIVES
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Selection of techniques
Order of efficacy of techniques
Ground the theory in reality
Application of techniques
How do you do what you should do
QUOTE FROM MAITLAND
Manipulative physiotherapy is not only
a matter of learning and applying
techniques. It is a matter of knowing
WHEN and HOW to use WHICH
technique, how to ADAPT the
technique to a particular situation of
the patient
SEQUENCE OF SELECTING
TECHNIQUES
• Also known as the order of efficacy.
• Determines which technique is used when.
• Indicates the progression from one
technique to the next
MOBILIZING TECHNIQUES AND THERE
USES IN LUMBER SPINE
• PA(C VP)
Bilateral distributed symptoms when
there are bony changes from any cause, it is useful as
rotation technique.
• PA(UVP)
unilateral distributed symptoms, (direct
the push downward on the site of pain)
• Transverse vertebral pressure
unilateral
distributed symptoms, useful in the upper lumber region
than lower lumber region (direct the push toward the side
of pain.
• Rotation
first technique used, unilaterally
distributed symptoms, (rotate the pelvis fwd. on the side
of pain)
MOBILIZING TECHNIQUES AND THERE
USES IN LUMBER SPINE
• LONGITUDINAL MOVEMENTS
two legs,
bilateral distributed symptoms of lower lumber in origin
one leg, of unilateral distributed symptoms of the lower
lumber in origin.
• FLEXION
bilateral distributed symptoms of
chronic in nature, flexion dysfunction
• TRACTION
gradual onset of symptoms , and
pain is not aggravated by active movements
• INTERMITTENT TRACTION
gross radiological
degenerative changes
• SLR
unilateral limitation of the SLR with out
extreme pain, for symptoms of chronic or stable nerve
root sumtoms
LUMBAR REGION
UNILATERAL PAIN
Rotation= PA(UVP)
UPPER LUMBER
• Transvers
• Traction
LOWER LUMBER
• Traction
• longitudinal
BILATERALSYMPTOMS
PA(CVP)
Rotation
UPPER LUMBER
• Transverse
• Traction
LOWER LUMBER
• Traction
• longitudinal
GUIDELINES FOR THE SELECTION
OF TECHNIQUE
• Cause and effect’ rule is used.
• Based on current knowledge of the pathological
disorder and structures of the vertebral column.
• Diagnosis – closely related to the history.
• History – signs and symptoms
ASPECTS OF KNOWLEDGE OF
PATHOLOGY
1. Movements and the related range/pain response.
2. Pain-sensitive Structures and their patterns.
3. The pathological disorders and injury.
1. MOVEMENTS
• Range of movement of the spine and each
segment.
• Differentiation from top-down or bottom-up
movement should be considered.
• Range/pain response to movement must be
considered.
– Stretching or compression.
– Point in the range pain occurs.
– Local or referred pain provoked.
PAIN-SENSITIVE STRUCTURES AND
THEIR RESPONSE
• Joint structures.
• Intervertebral disc, ligaments, facet joints,
• bones, blood vessels, tendons, muscles
• fascia and aponeuroses.
• Pain-sensitive structures
– In the CANAL and the IV FORAMEN
– The dura, nerve root sleeves, nerve roots and their rootlets
THE INTERVERTEBRAL DISC
HERNIATING IV DISC
• Herniating nuclear material causes a bulge in the annulus
• If spinal stenosis is present symptoms may travel down
the leg
• Pain and pins and needles are common.
• Level of pain determined by the level of irritation.
• Distal pain usually not greater than the central pain.
DURA AND NERVE ROOTS
• Dural signs - distal pain is not greater than the central
pain.
• Root sleeve pain - referred to foot
• Pins and needles present
• Nerve root - symptoms in the distal part of the
dermatome.
• Testing structures that cause pain can differentiate
causes of the pain - disc versus nerve root irritation.
STABILITY ISSUES
• Stability of the disorder has an influence on the intensity
of assessment and treatment.
• No clear sign patterns of pain for old herniated
disc/nerve root situations.
• Relationship between structures must be considered.
• Joint structure involvement - ‘through range’ and ‘end
range’ pain described
• DIAGNOSIS
ASPECTS OF PAIN THAT INFLUENCE
SELECTION
SELECTION OF THE TECHNIQUE
• Decide whether you want to mobilize or
manipulate.
• Identify the direction of the movement.
• Identify the position in which the directed
movement would be performed.
• Identify the manner of the technique.
• Consider the duration of the treatment
GROUP 1 – PAIN
• Patients have severe pain limiting movement.
• Accessory movements in the part of the range that is
completely pain free.
• Positioned in a painless position and large amplitude
movements used.
• The rhythm should be smooth and slow.
• Physiological movements should not provoke
symptoms.
• Progress into a controlled degree of discomfort.
PAIN-MOTION SEQUENCE
• Pain before restriction of motion
– Indicative of an active and often acute lesion such as a
sprain or strain
–Treat with protection, rest, ice, compression, elevation as
indicated
 Mobilization is contraindicated
• Pain at the point of restricted motion
– Indicative of sub-acute stage of recovery
–Continue modalities with cautious and progressive
movement and mobilization as indicated
PAIN-MOTION SEQUENCE
• Restriction of motion before pain
– Indicative of chronic dysfunction and lack of recovery
–Modalities as needed and motion and mobilization are
indicated
• Pain without restriction
–Usually indicative of impingement type syndromes
–Can occur with tumors and/or vascular disorders
–Exercise and modalities are the treatment of choice for
impingement syndromes
GROUP 2 – PAIN WITH STIFFNESS
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Largest and most challenging group to treat.
Movement will be stiff and will elicit pain.
Need to identify the dominant factor - pain or stiffness.
Graphically portrayed by movement diagrams.
Initially only accessory or physiological movements are
used - not both.
• Decide on whether to use accessory or physiological
movements
GROUP 3 – STIFFNESS
• Stiffness limits normal function - not pain.
• Use two kinds of stretching movements - alternating from
one side to the other.
• Physiological movement with end range stretching.
• Followed by Accessory movements in the same
direction.
GROUP 4 – MOMENTARY PAIN
• Pain occurs unexpectedly as a sudden ONSET.
• Always associated with movement.
• Technique selection depends on the movements which
elicited pain.
• Identify the combined movement that causes pain and
treat using the appropriate accessory movement.
• Technique is nearly always a strong grade IV followed by
gentle grade III movements
GROUP 5 – ARTHRITIC FACET JOINT
• Pain through-range occurs.
• Treated in the same way as for Group 1 - Pain.
• Decision should be made as to whether to treat this type
of pain as a normal orthopedic joint or as a spinal
problem.
• If treating by mobilization this may not succeed and
manipulation may be required at the faulty level
DISC OR NERVE ROOT
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If severe enough surgery may be indicated.
Less severe symptoms do not prevent light work.
Chronic remnants of nerve-root symptoms.
Position of ease may be necessary and movements
should provide ease as well.
• Select appropriate technique according to the order of
efficacy.